Heading into my 5th fall sports season since moving back to the south, and the 5th fall sports season since passage of Georgia’s “Concussion Law” that mandates concussion education for high-school athletes and coaches, it is admittedly disappointing to realize that there has not been much change in the prevailing local concussion management guidelines distributed to Georgia schools that provide the blueprint for the return-to-learn and to play.

Fortunately, however, we have the recent CDC guidelines – published in the last few weeks – that reflect the changes that have been practiced by sports-concussion experts and sports neuropsychologists for several years, and as a supplement to the Berlin Guidelines and statements from related professional organizations that also contradict much of the current standard practices. Among the highlights:

Avoid prolonged rest! “Rest” does not mean to sit in a dark room, avoid electronics, tests, and socializing, and staying out of school for more than a couple of days. Rather, it means managing, manipulating, modifying, activities or triggers that lead to a worsening of symptoms. Big difference there!

Offer symptom-specific school-based supports. These are not “one-size-fits-all” but should be individualized based on each individual’s symptom-profile, context, risk factors, and history.

Do consider risk factors for prolonged recovery, and refer out to specialists if symptoms are prolonged.

There is no data to support the utility of widespread, large-scale baseline testing. When it is administered, it should be under structured testing conditions with some guidance or oversight by experts in neurocognitive / neuropsychological testing who can attest to the validity and the reliability of each child’s scores.

There is no medical basis to remove cell phones, limit coloring to child vs. adult coloring books, carbo-load, or to recommend certain fixed portions of school days or no testing, all recommended to students I’ve seen over the last few weeks. Again, management needs to be individualized and symptom-specific, with modifications as needed to avoid activities associated with symptom increase – that is, it’s not black/white, all/nothing, or limited to what’s listed on a pre-printed form, though checklists are always good places to start.

The steady increase of media attention to concussions has largely been a good thing – with increased awareness comes increased scrutiny and education. The downside, though, is that it also seems to bring with it a lot of inaccurate information that is frequently sensationalized to grab headlines. Sometimes it’s intentional, sometimes it’s not.

Along with the media hype, we also see an increase in personal testimonials, also with their pros and cons. Folks love a good story – especially a comeback story! – and it’s also very helpful for individuals who are struggling to realize that they’re not alone, and that there’s hope.

What’s most frustrating to me about these testimonials, though, is when they seem to inadvertently convey mistruths about injury and recovery. A recent release by the CDC – typically a source of balanced, trusted information – seemed to do this and left me feeling particularly compelled to respond because their concussion-related information is characteristically well-researched and accurate.

The most troubling thing to me about this article was how it described this athlete’s months-long recovery; the absence of any critical or editorial comments about that aspect of this athlete’s injury seemed to convey that this is typical, when it absolutely should not be. While we know that everyone recovers at their own rate, and that risk-factors such as one’s history of previous concussions, psychiatric issues, and medical factors can prolong recovery, it’s widely accepted that 80-85% of young adults will recover fully in 2-3 weeks, with 90% achieving complete recovery within a month, if properly managed.

Note the emphasis on proper management – this, too, will vary from person to person – there is no one-size-fits-all handout or formula that truly works – but will generally include such factors as:

Appropriate lifestyle adjustments – remaining engaged in school and social activities, but with sufficient adjustments and supports to remain sub-symptom threshold, with gradual withdrawal over recovery

Headache management – by a good neurologist with particular expertise in concussion-related headaches; I refer if headaches are persisting past a week despite appropriate behavior changes, with consideration of cervicogenic causes, too

Consultation with cognitive-behavioral psychologist if stress and wound-too-tightness are interfering with treatment compliance

So, when I hear stories of recovery extending over many months, I not only wonder where things went wrong, I am also concerned that this will only serve to perpetuate the “suck-it-up-and-don’t-tell” culture out of fear that one’s likely to miss the season if symptoms are reported.

I much prefer the CDC’s mantra – “Better to miss one game than the whole season” – but we need to make sure the stories that are circulated behind it are consistent, and that they represent the current best standards of care. Or, if not, that there are at least some qualifiers for the lay public and related healthcare providers who would not know differently and otherwise presume that this is just the new normal.

“Colleges spend a huge sum each year sending signals that influence the behavior of millions of students,” the report notes. Why not rethink those signals to reshape that behavior?”
Spending 2½ years working solely with thousands of students with sports-related concussions, each needing lifestyle and school-related adjustments to facilitate recovery, provided me with an invaluable education on the academic lifestyle of high-achieving student-athletes. It’s not that I was completely isolated and insulated before that, but spending that much time with so many students in a short period of time allowed me to see what’s really typical across high schools and school districts in a way I’ve never experienced before, even as an involved high-school mom and school volunteer myself.

The Harvard report touched on many of the trends I observed, and that are of great concern to me as both a mom and pediatric psychologist. Among them:

Our kids are stressed! From the CDC’s biannual Youth Health Risk Behavior2 survey, approximately 30% of surveyed high-schoolers reported significant sadness or hopelessness over the 12-month survey period, with 17% reporting that they had seriously considered suicide in the previous year. That’s concerning, to say the least.

Our kids are over-extended, largely in their drive to succeed, to be the best, to get into the best colleges – it’s not uncommon for me to meet high-school sophomores, juniors, or seniors taking multiple college-level (AP) classes, in addition to honors classes, team sports, and volunteer commitments. That’s quite an intense load – and if you’re at practice or club meetings until late afternoon, and AP teachers are requiring 1-2 hours homework per class at night, the reality is that students should be staying up very late to complete all of their homework, but sacrificing a good night’s sleep in the process… not to mention time to relax or socialize.

With these workloads, is it any wonder that they’re sleep-deprived, too? This seems to be SOP – and acceptable, while parents often say “but I can’t make them go to bed.”

The risks of inadequate sleep are not negligible:

Impaired attention, memory and learning

Weaker retention of learned information

Increased moodiness, irritability

Decreased resistance to infection

Decreased physical performance in sport, and increased risk of injury

So, what are the solutions? If the Harvard report’s recommendations are truly implemented, that’s a great start – behaviors can change in response to changed demands. In the meantime, though, parents can help by being parents – that is, imposing limits, and guiding our children to make good choices. We can also remember that we’re our children’s role models, and take a hard look at our own behavior with respect to workload, commitments, and life balance. In other words, start by leading by example, and learning new habits together.

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